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Corneal lacerations are common in ocular trauma. Repair should occur within 24 hours to reduce the risk of infection, alleviate patient discomfort, and avoid further damage to the eye. The goal for repair is a watertight closure, restoration of normal anatomy, and prevention of high astigmatism or scarring. This activity reviews the evaluation and management of corneal lacerations and highlights the role of the interprofessional team in managing this condition. Objectives: Identify the initial steps for evaluation when evaluating a patient with an eye injury. Describe the process for treatment of a corneal laceration. Review surgical techniques for repairing a corneal laceration. Summarize the postoperative complications that can occur after a corneal laceration repair. Access free multiple choice questions on this topic.

Ocular injury is common, with an estimated 24 million people in the United States suffering an eye injury.[1] Injuries to the eye vary in severity, from a small scratch to the cornea (corneal abrasion) to a split in the external structure (globe rupture). Globe rupture can occur in various parts of the eye; one example is a corneal laceration. In a review of 890 eye injuries in Iraq and Afghanistan from 2001 to 2011, 20.7% involved a corneal laceration.[2] Corneal lacerations vary in size and shape, can be partial or full-thickness, and range from a simple linear pattern to a complex stellate formation. All lacerations require urgent repair to reduce the risk of infection, decrease tissue necrosis, and alleviate patient discomfort. The typical recommendation for a repair is within 24 hours.[3] The repair of a corneal laceration often requires suturing; however, tissue adhesives or contact lenses can close lacerations less than 2 mm.[4] The goal of any repair is a watertight closure, restoration of normal anatomy, and limiting the amount of post-operative corneal scarring and astigmatism.[5][6]

Complications are avoidable with preoperative and postoperative antibiotics and proper intraoperative surgical technique. Posttraumatic Endophthalmitis Posttraumatic endophthalmitis is a devastating condition that occurs from 3.3% to 17% in penetrating trauma. The primary risk factors are a delay of primary surgical repair and violation of the lens capsule. The diagnosis can be difficult because the eye is already inflamed from the trauma and surgery.[26] Symptoms can be non-specific, including ocular pain, redness, eyelid swelling, discharge, decreased vision, and floaters. Treatment recommendations vary from a vitreous tap and injection with broad-spectrum antibiotics to a vitrectomy if vision is light perception or worse.[27] Retained Intraocular Foreign Body Intraocular foreign bodies in ocular trauma occur from 18 to 41%.[28] Ocular imaging prior to the surgical repair can identify foreign bodies. Sometimes foreign bodies can not be removed during a surgical repair, especially if located in the vitreous, so that further surgery may be necessary. Most foreign bodies are metallic and toxic to the eye; therefore, removal is recommended.[28] Wound Leak Evaluate the patient the day after the primary surgical repair with fluorescein to check for a wound leak. If a wound leak is present, a bandage contact lens or cyanoacrylate glue may seal it. If the leak is too brisk or large, more suturing is required to create a watertight closure. Wound leaks significantly increase the risk of infection.[29] Suture Issues Unburied knots and broken or loose sutures can cause the patient discomfort and serve as a track for microorganisms. All suture knots should be buried at the time of surgery; however, if recognized during the postoperative period, a knot can be rotated at the slit lamp. The timing of suture removal is variable depending on the patient's age, size of the laceration, and refractive anomaly induced by the suture.[30] However, remove broken or loose sutures immediately. Iris Damage The iris can tear or dislodge from its root through the initial trauma or during surgical repair. An abnormal iris can cause photophobia, visual disturbances, and an unpleasant aesthetic appearance.[31][32] Surgical techniques, corneal tattooing, contact lens, and artificial iris implants are available if the patient is symptomatic.[33][34] Cataract

The iris can tear or dislodge from its root through the initial trauma or during surgical repair. An abnormal iris can cause photophobia, visual disturbances, and an unpleasant aesthetic appearance.[31][32] Surgical techniques, corneal tattooing, contact lens, and artificial iris implants are available if the patient is symptomatic.[33][34] Cataract Cataracts can form from the initial trauma or during the operative repair if the lens capsule is violated. The majority of traumatic cataracts can safely be removed and replaced with a posterior or scleral-fixated lens to improve vision.[35] Infectious Keratitis Infectious keratitis can occur following trauma by various organisms.[36] Bacteria can build up on the sutures or form abscesses.[37] Treatment typically starts with fluoroquinolones, although fortified broad-spectrum antibiotics may be necessary for severe infections or resistant bacteria. Retinal Detachment Retinal detachments can occur during the trauma or subsequently in the postoperative period. Early intervention is key to preventing vision loss. Posttraumatic Glaucoma It is not uncommon for secondary glaucoma to occur from penetrating trauma due to various mechanisms.[38] Monitor the intraocular pressure during the postoperative period and counsel the patient about the long-term risk. Sympathetic Ophthalmia Sympathetic ophthalmia is an uncommon immune reaction that occurs in the non-traumatic eye after injuries or surgeries involving the uveal tissue.[39] Suspect this condition if inflammation occurs in the non-traumatic eye. The classic doctrine taught was to enucleate the traumatic eye within two weeks to prevent this condition; however, the current doctrine encourages leaving the traumatic eye in place if there is any vision still present.[40] Vision Loss

Sympathetic ophthalmia is an uncommon immune reaction that occurs in the non-traumatic eye after injuries or surgeries involving the uveal tissue.[39] Suspect this condition if inflammation occurs in the non-traumatic eye. The classic doctrine taught was to enucleate the traumatic eye within two weeks to prevent this condition; however, the current doctrine encourages leaving the traumatic eye in place if there is any vision still present.[40] Vision Loss Vision loss can occur from all of the complications discussed in this section. Traumatic damage to the optic nerve or other parts of the eye can also lead to vision loss. Corneal scarring, neovascularization, and irregular astigmatism are common reasons for decreased vision after a corneal laceration. Hard contact lenses can be helpful to determine if the visual complaint is related to the cornea versus other parts of the eye. A special fit contact lens can often improve vision significantly.[41] If the vision loss is related to corneal pathology and not improved with a contact lens, a corneal transplant may be beneficial once the eye has completely healed from the trauma.[42]

Improving outcomes for ocular trauma, including corneal lacerations, requires a team approach. Although the ophthalmologist performs the repair, many others help throughout the process. The initial step in the process is identifying a corneal laceration. Prompt recognition of an ocular injury by a bystander at the scene of the injury, paramedic, emergency room nurse, physician, or optometrist expedites the repair. After identifying the corneal laceration, cover the eye with a rigid eye shield to prevent further damage, and transfer the patient to an ophthalmologist. Occasionally, a patient is incorrectly diagnosed with a corneal abrasion which can delay the repair. In the ocular blast injuries from the Boston Marathon bombing and the West Texas fertilizer explosion, only 28% of the patients had ophthalmology consulted from the emergency room.[50] The patient and family members almost always want to know if the patient’s vision will return to normal. Based on the United States Eye Registry, over 27% of the injuries involved permanent vision impairment. The Ocular Trauma Score is a tool for predicting the final vision of the injured eye and can be used by the team to educate the patient or their family.[51] Nurses are vital members of the interprofessional group as they will monitor the patient’s vital signs, especially the pain level, pre-operatively and post-operatively. The radiologist has a role in identifying foreign bodies on facial computed tomography and can often confirm an open globe injury.[52] The pharmacist ensures the patient is on the correct analgesics, antiemetics, and antibiotics. If an infection is present or develops in the postoperative course, specialized fortified antibiotics may need to be compounded by the pharmacist. The surgeon, surgical technician, operating nurse, and anesthesia provider all have roles in the outcome of the surgery. A well-organized surgical timeout that all members participate in improves patient safety. In the surgical repair, the surgical technician passes instruments to the surgeon, prevents needle stick injuries, and ensures correct needle counts. The anesthesia provider is vital to prevent the patient from moving during the surgical repair. Abrupt movements from the patient can lead to tissue protrusion and worsen the injury.

The surgeon, surgical technician, operating nurse, and anesthesia provider all have roles in the outcome of the surgery. A well-organized surgical timeout that all members participate in improves patient safety. In the surgical repair, the surgical technician passes instruments to the surgeon, prevents needle stick injuries, and ensures correct needle counts. The anesthesia provider is vital to prevent the patient from moving during the surgical repair. Abrupt movements from the patient can lead to tissue protrusion and worsen the injury. All team members educate the patient and family about postoperative care to include compliance with medications, signs of complications, activity limitations, and expected symptoms throughout the recovery process. Setting realistic expectations is important because many cases result in poor outcomes.[53] A corneal laceration will change the refractive error of the patient. The patient may need a special contact lens fitting by an optometrist or an update in their prescription glasses to improve the visual outcome. The technological advances in contact lenses have improved patient visual outcomes after ocular trauma. A study of 214 patients with an open globe injury demonstrated a visual acuity improvement in 97% of the patients with a contact lens.

The first person to recognize an eye injury should intervene and place a rigid eye shield over the eye. Nurses are vital in keeping the patient calm before the repair. Control of pain and nausea before and after the repair is necessary. Antibiotics should be administered at the onset of the injury and continued throughout the recovery period. Any member of the care team should speak up if they notice anything unsafe or have any concerns.

Monitoring a patient's pain, nausea, and other vitals should occur before and after the repair. After the repair, the patient is either discharged home with a follow-up visit the next day in the clinic or kept overnight in the hospital for observation. During the postoperative period, especially the first week, all team members should monitor for signs of infection such as increased pain or decreased vision. On the day of discharge, clear instructions from every team member to educate the patient about follow-up are paramount because many ocular trauma patients will not return.[54]